Conventional and Complementary Health Care Approaches Used by American Adults Reporting Joint Pain: Patterns from the National Health Interview Survey 2012.

Objective: To describe patterns of conventional health care (CH) and complementary and alternative medicine (CAM) use among U.S. adults reporting recent joint symptoms in a nationally representative sample. Design: This study uses the adult alternative medicine supplement from the 2012 National Health Interview Survey (NHIS). Location: United States. Subjects: Nationally representative cross-sectional sample of non-institutionalized U.S. residents. Of 34,525 respondents who answered the alternative medicine supplement, approximately 30% (n = 10,964) reported recent pain symptoms (pain, aching, stiffness). Outcome measures: Among adults reporting joint symptoms, we examine reported use of CH, CAM, both CH and CAM, or neither specifically for joint symptoms or joint condition. Results: Among adults reporting joint symptoms in the past 30 days, 64% reported using only CH for their joint pain, whereas ∼10% reported using CAM. Among those using CAM for their joint symptoms, 83% also sought help from a CH practitioner. CAM-only users comprised only 1.6% of the sample of joint pain sufferers. Those who reported using both CH and CAM for joint pain were more likely to report a diagnosis of a joint condition compared with CAM-only users, but also reported higher comorbidities and worse self-reported health. Conclusion: Most U.S. adults reporting recent joint pain seek care only from a CH practitioner, although among the 10% who report CAM use for joint conditions, a strong majority also report seeking care from a CH practitioner. CH and CAM providers should consistently inquire about other forms of treatment their patients are using for specific symptoms to provide effective integrative health care management.

The effect of mindfulness training prior to total joint arthroplasty on post-operative pain and physical function: A randomised controlled trial.

OBJECTIVE: To evaluate the efficacy of Mindfulness-Based Stress Reduction (MBSR) in improving pain and physical function following total joint arthroplasty (TJA). DESIGN: Two-group, parallel-group, randomised controlled trial, conducted between September 2012 and May 2017. SETTING: Single centre study conducted at a University-affiliated, tertiary hospital. INTERVENTION: People with arthritis scheduled for TJA, with a well-being score <40 (Short Form-12 Survey) were randomly allocated to a pre-surgery eight-week MBSR program or treatment as usual (TAU). OUTCOME MEASURES: Self-reported joint pain and function at 12 months post-surgery, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes were knee stiffness and global improvement (WOMAC); physical and psychological well-being (Veterans RAND 12-item Health Survey); self-efficacy (Arthritis Self-Efficacy Scale); and mindfulness (5-Factor Mindfulness Questionnaire). RESULTS: 127 participants were randomised; 65 to MBSR and 62 to TAU, of which 45 participants allocated to the intervention and 56 participants allocated to usual care proceeded to surgery and 100 (99%) completed primary outcome measures. Greater improvements in knee pain (mean difference, -10.3 points, 95% CI -19.0 to -1.6; P = 0.021) and function (mean difference, -10.2 points, 95% CI -19.2 to -1.3; P = 0.025) at 12 months post-surgery were observed in the MBSR group compared to the TAU group. A between group difference in global scores (-9.5 points, 95% CI -17.9 to -1.1; P = 0.027) was also observed. No other differences in secondary outcomes were observed. CONCLUSION: MBSR improves post-surgery pain and function in people with psychological distress undergoing TJA. Further research is required to examine potential barriers to broader implementation and uptake.

Relationship Between Opioid Analgesic Prescription and Unemployment in Patients Seeking Acupuncture for Chronic Pain in Urban Primary Care.

OBJECTIVE: The widespread use of opioid analgesics to treat chronic nonmalignant pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality. Previous studies have also demonstrated a relationship between opioid analgesic use and unemployment due to disability. These studies have been limited to mainly white European and North American populations. The objective of this study is to explore the relationship between opioid analgesic use for chronic nonmalignant pain in an urban, mainly black and Hispanic, low-income population. DESIGN: This is a cross-sectional observational study. SETTING: Subjects were recruited from six urban primary care health centers. SUBJECTS: Adults with chronic neck, back, or osteoarthritis pain participating in an acupuncture trial were included. METHODS: Survey data were collected as a part of the Acupuncture Approaches to Decrease Disparities in Pain Treatment two-arm (AADDOPT-2) comparative effectiveness trial. Participants completed a baseline survey including employment status, opioid analgesic use, the Brief Pain Inventory, the global Patient Reported Outcomes Measurement Information Systems quality of life measure, the Patient Health Questionnaire-9 (PHQ-9), and demographic information. A multivariable logistic regression model was built to examine the association between opioid analgesic use and unemployment. RESULTS: Opioid analgesic use was associated with three times the odds of unemployment due to disability while controlling for potential confounders, including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics. CONCLUSIONS: This study adds to the growing body of evidence that opioid analgesics should be used with caution in chronic nonmalignant pain.

A Functional Neuroimaging Study of Expectancy Effects on Pain Response in Patients With Knee Osteoarthritis.

Placebo treatments and healing rituals share much in common, such as the effects of expectancy, and have been used since the beginning of human history to treat pain. Previous mechanistic neuroimaging studies investigating the effects of expectancy on placebo analgesia have used young, healthy volunteers. Using functional magnetic resonance imaging (fMRI), we aimed to investigate the neural mechanisms by which expectancy evokes analgesia in older adults living with a chronic pain disorder and determine whether there are interactions with active treatment. In this fMRI study, we investigated the brain networks underlying expectancy in participants with chronic pain due to knee osteoarthritis (OA) after verum (genuine) and sham electroacupuncture treatment before and after experiencing calibrated experimental heat pain using a well tested expectancy manipulation model. We found that expectancy significantly and similarly modulates the pain experience in knee OA patients in both verum (n = 21, 11 female; mean ± SD age 57 ± 7 years) and sham (n = 22, 15 female; mean ± SD age 59 ± 7 years) acupuncture treatment groups. However, there were different patterns of changes in fMRI indices of brain activity associated with verum and sham treatment modalities specifically in the lateral prefrontal cortex. We also found that continuous electroacupuncture in knee OA patients can evoke significant regional coherence decreases in pain associated brain regions. Our results suggest that expectancy modulates the experience of pain in knee OA patients but may work through different pathways depending on the treatment modality and, we speculate, on pathophysiological states of the participants. PERSPECTIVE: To investigate the neural mechanisms underlying pain modulation, we used an expectancy manipulation model and fMRI to study response to heat pain stimuli before and after verum or sham acupuncture treatment in chronic pain patients. Both relieve pain and each is each associated with a distinct pattern of brain activation.

Omega-6: Omega-3 PUFA Ratio, Pain, Functioning, and Distress in Adults With Knee Pain.

OBJECTIVES: Osteoarthritis (OA) is associated with inflammation, chronic pain, functional limitations, and psychosocial distress. High omega-3 (n-3) polyunsaturated fatty acids (PUFAs) are associated with lower levels of inflammatory mediators, anti-nociception, and adaptive cognitive/emotional functioning. High omega-6 (n-6) PUFAs are associated with inflammation, nociception, and psychological distress. While findings related to n-3 supplementation in knee OA are mixed, consideration of the n-6:n-3 ratio and additional outcome measures may provide improved understanding of the potential relevance of these fatty acids in OA. On the basis of recommended and typical ranges of the n-6:n-3 ratio, we hypothesized that in adults with knee pain, those with a high n-6:n-3 ratio would have greater pain/functional limitations, experimental pain sensitivity, and psychosocial distress compared with those with a low n-6:n-3 ratio. MATERIALS AND METHODS: A cross-sectional investigation of clinical and experimental pain and physical and psychosocial functioning was completed in 167 adults ages 45 to 85 meeting knee OA screening criteria. Blood samples were collected and the plasma n-6:n-3 PUFA ratio determined. Quartile splits were computed and low (n=42) and high (n=41) ratio groups were compared. RESULTS: The high ratio group reported greater pain and functional limitations, (all Ps<0.04), mechanical temporal summation (hand and knee, P<0.05), and perceived stress (P=0.008) but not depressive symptoms. DISCUSSION: In adults with knee pain, a high n-6:n-3 ratio is associated with greater clinical pain/functional limitations, experimental pain sensitivity, and psychosocial distress compared with a low ratio group. Findings support consideration of the n-6:n-3 PUFA ratio and additional clinical endpoints in future research efforts.

Multisite peripheral joint pain: a cross-sectional study of prevalence and impact on general health, quality of life, pain intensity and consultation behaviour.

BACKGROUND: Research into musculoskeletal conditions often focusses on pain at single sites, such as the knee, yet several studies have previously reported the high prevalence of multiple sites of musculoskeletal pain. The most common form of musculoskeletal condition is arthritis, with osteoarthritis (OA) the most common cause of joint pain in adults 45 years and over. However, there is limited recognition of the prevalence of multisite peripheral joint pain in those either living with or at risk of OA, therefore this study set out to estimate the prevalence of multisite peripheral joint pain in adults 45 years and older, and its impact on several dimensions of health. METHODS: A cross-sectional population survey was mailed to adults (n = 28,443) aged 45 years and over from eight general practices in the North West Midlands, United Kingdom (UK). Prevalence rates were established for multisite peripheral joint pain (pain in two or more sites; hands, hips, knees, feet). Impact was measured for general health (SF-12 MCS & PCS), QoL (EQ-5D), pain intensity (0-10 numerical ratings scale) and the number of consultations with a range of health care professionals. RESULTS: Of 15,083 responders (53%), multisite peripheral joint pain was reported by 54%. Peripheral joint pain was present in n = 11,928, of which 68% reported pain in multiple sites. Multisite peripheral joint pain was shown to be significantly associated with reduced physical (Mean difference = -5.9 95% CI -6.3,-5.5) and mental (-2.8 95% CI -3.2,-2.4) components of the SF-12, reduced QoL (-0.14 95% CI -0.15, -0.13), increased pain (+0.70 95% CI 0.62, 0.79) and increased odds of consultations with GPs (OR 2.4 95% CI 2.2, 2.6) and practice nurses (OR 2.6 (95% CI 2.1, 3.2) when compared to single site pain. CONCLUSIONS: Multisite peripheral joint pain is prevalent in the population in adults 45 years and over and has a significant negative impact on several dimensions of health. Health care professionals should consider joint pain beyond the index site in order to address holistic management.

Effect of aquatic physical therapy on pain perception, functional capacity and quality of life in older people with knee osteoarthritis: study protocol for a randomized controlled trial.

BACKGROUND: Aquatic therapy promotes short-term benefits for patients with knee osteoarthritis (OA), and it may be the first therapeutic option for this pathological condition. The objective of this study was to investigate the effects of an aquatic therapy program on pain intensity, functional ability, and quality of life in older people with knee OA. METHODS/DESIGN: This is a parallel, two-arm, open, randomized controlled clinical trial with older people with knee OA. Volunteers will be allocated to an aquatic intervention group (WG), subjected to the intervention, or to a control group, not be subjected to any kind of intervention. Data collection pre- and postintervention will be composed of the evaluation of the perception of pain by visual analogue scale with application of nociceptive stimuli in four anatomical points of the knee, functional fitness tests, and application of the World Health Organization Quality of Life Scale abbreviated version and Western Ontario and McMaster Universities Osteoarthritis Index. The program will last 12 weeks, consisting of aerobic and functional exercises in the form of circuit training. DISCUSSION: The objective of this clinical trial is to evaluate the effect of aquatic therapy in elderly patients with knee OA. The study is guided by practice-based scientific evidence for the use of aquatic rehabilitation exercises. It is expected that the WG volunteers will show reduced pain intensity, increased flexibility, and improved functional capacity and quality of life. It is believed that the desired results can be attributed to physical and physiological effects of immersion in warm water associated with the exercise protocol proposed. The data will be published after completion of the study. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials (ReBEC) registration number: RBR-78h48d . Registered on 19 August 2015.

Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis.

The current study aimed to examine the relationships between movement and resting pain intensity, pain-related distress, and psychological distress in participants scheduled for total knee arthroplasty (TKA). This study examined the impact of anxiety, depression, and pain catastrophizing on the relationship between pain intensity and pain-related distress. Data analyzed for the current study (N = 346) were collected at baseline as part of a larger Randomized Controlled Trial investigating the efficacy of TENS for TKA (TANK Study). Participants provided demographic information, pain intensity and pain-related distress, and completed validated measures of depression, anxiety, and pain catastrophizing. Only 58% of the sample reported resting pain >0 while 92% of the sample reported movement pain >0. Both movement and resting pain intensity correlated significantly with distress (rs = .86, p < .01 and .79, p < .01, respectively). About three quarters to two thirds of the sample (78% for resting pain and 65% for movement pain) reported different pain intensity and pain-related distress. Both pain intensity and pain-related distress demonstrated significant relationships with anxiety, depression, and catastrophizing. Of participants reporting pain, those reporting higher anxiety reported higher levels of distress compared to pain intensity. These findings suggest that anxious patients may be particularly distressed by movement pain preceding TKA. Future research is needed to investigate the utility of brief psychological interventions for pre-surgical TKA patients.

Outcome Expectations and Osteoarthritis: Association of Perceived Benefits of Exercise With Self-Efficacy and Depression.

OBJECTIVE: Outcome expectancy is recognized as a determinant of exercise engagement and adherence. However, little is known about which factors influence outcome expectations for exercise among people with knee osteoarthritis (OA). This is the first study to examine the association of outcome expectations for exercise with demographic, physical, and psychosocial outcomes in individuals with knee OA. METHODS: We performed a cross-sectional analysis of the baseline data from a randomized trial of tai chi versus physical therapy in participants with symptomatic knee OA. Knee pain was evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Outcome expectations for exercise, self-efficacy, depression, anxiety, stress, and social support were measured using standard instruments. Logistic regression models were utilized to determine associations with outcome expectations. RESULTS: There were 262 participants, with a mean age of 59.8 years and a mean body mass index of 32.1 kg/m2 ; 69.1% of the participants were female, 51.5% were white, the mean disease duration was 8.6 years, and the mean WOMAC knee pain and function scores were 260.8 and 906.8, respectively. Higher outcome expectations for exercise were associated with greater self-efficacy (odds ratio [OR] 1.25 [95% confidence interval (95% CI) 1.11-1.41]; P = 0.0004), as well as with fewer depressive symptoms (OR 0.84 for each 5-point increase [95% CI 0.73-0.97]; P = 0.01). Outcome expectancy was not significantly associated with sex, race, education, pain, function, radiographic severity, social support, anxiety, or stress. CONCLUSION: Our results suggest significant associations between outcome expectations for exercise and self-efficacy and depression. Future studies should examine how these relationships longitudinally affect long-term clinical outcomes of exercise-based treatment for knee OA.

Mindfulness is associated with psychological health and moderates pain in knee osteoarthritis.

OBJECTIVE: Previous studies suggest that higher mindfulness is associated with less pain and depression. However, the role of mindfulness has never been studied in knee osteoarthritis (OA). We evaluate the relationships between mindfulness and pain, psychological symptoms, and quality of life in knee OA. METHOD: We performed a secondary analysis of baseline data from our randomized comparative trial in participants with knee OA. Mindfulness was assessed using the Five Facet Mindfulness Questionnaire (FFMQ). We measured pain, physical function, quality of life, depression, stress, and self-efficacy with commonly-used patient-reported measures. Simple and multivariable regression models were utilized to assess associations between mindfulness and health outcomes. We further tested whether mindfulness moderated the pain-psychological outcome associations. RESULTS: Eighty patients were enrolled (60.3 ± 10.3 years; 76.3% female, body mass index: 33.0 ± 7.1 kg/m2). Total mindfulness score was associated with mental (beta = 1.31, 95% CI: 0.68, 1.95) and physical (beta = 0.69, 95% CI:0.06, 1.31) component quality of life, self-efficacy (beta = 0.22, 95% CI:0.07, 0.37), depression (beta = -1.15, 95% CI:-1.77, -0.54), and stress (beta = -1.07, 95% CI:-1.53, -0.60). Of the five facets, the Describing, Acting-with-Awareness, and Non-judging mindfulness facets had the most associations with psychological health. No significant association was found between mindfulness and pain or function (P = 0.08-0.24). However, we found that mindfulness moderated the effect of pain on stress (P = 0.02). CONCLUSION: Mindfulness is associated with depression, stress, self-efficacy, and quality of life among knee OA patients. Mindfulness also moderates the influence of pain on stress, which suggests that mindfulness may alter the way one copes with pain. Future studies examining the benefits of mind-body therapy, designed to increase mindfulness, for patients with OA are warranted.

A cross-sectional survey of pain catastrophising and acupuncture use among breast cancer survivors.

INTRODUCTION: Treatment-related joint pain affects almost half of all women with breast cancer using aromatase inhibitors and is a major reason for terminating treatment. Although acupuncture is becoming an increasingly popular, evidence-based option for treating pain, little is known about the potential influence of psychological factors on acupuncture use. OBJECTIVE: We aimed to evaluate the association between pain catastrophising and use of acupuncture in breast cancer survivors experiencing arthralgia. METHODS: We conducted a cross-sectional survey of arthralgic breast cancer patients. Patients were asked if they had used acupuncture since their cancer diagnosis. The Pain Catastrophising Scale (PCS) was used to measure negative coping styles related to the experience of pain. We performed multiple logistic regression analysis to evaluate the relationship between pain catastrophising and acupuncture use, adjusting for covariates. RESULTS: Of the 424 participants, 69 (16%) reported use of acupuncture since their breast cancer diagnosis. In multivariate analyses, compared to those in the lowest PCS score tertile, patients with the highest PCS scores were more likely to have used acupuncture (p=0.03). In particular, patients with high levels of rumination (p=0.005) and magnification (p=0.008) were more likely to have used acupuncture. Helplessness was not associated with acupuncture use (p=0.23). CONCLUSIONS: High levels of pain catastrophising, and specifically the processes of rumination and magnification, were associated with greater acupuncture use. We believe this could have important implications for understanding which population is more likely to seek acupuncture treatment and how this alternative therapy could be better targeted to these patients.

Treatment Seeking and Self-Constructed Explanations of Pain and Pain Management Strategies Among Adolescents with Temporomandibular Disorder Pain.

AIMS: To explore adolescents' explanations of their temporomandibular disorder (TMD) pain, their pain management strategies for TMD pain, and their treatment-seeking behavior. METHODS: One-on-one interviews were conducted with 21 adolescents aged 15 to 19 years who had TMD pain and followed a semistructured interview guide. Subjects were strategically selected from patients referred to an orofacial pain clinic. All participants had been examined and received a pain diagnosis based on the Research Diagnostic Criteria for TMD. The interviews focused on the adolescents' experiences of TMD pain, their strategies for handling pain, and how they seek care. The interviews were recorded, transcribed verbatim, and analyzed using qualitative manifest content analysis. RESULTS: Qualitative manifest content analysis revealed two categories: (1) self-constructed explanations, with three subcategories (situation-based explanatory model, physical/biologic model, and psychological explanatory model); and (2) pain management strategies, with four subcategories (social support, treatment, relaxation/rest, and psychological strategies). Adolescents used physical activities and psychological and pharmacologic treatment to manage pain. Reasons for seeking treatment were to be cured, to obtain an explanation for their pain, and because their symptoms bother others. CONCLUSION: Adolescents living with TMD pain develop self-constructed explanations and pain management strategies. With access to these descriptions, dentists can be better prepared to have a dialogue with their adolescent patients about their own explanations of pain, the nature of pain, and in which situations the pain appears. Dentists can also explore adolescent patients' pain management strategies and perhaps also suggest new treatment strategies at an earlier stage.

A clinical trial comparing Lanconone® with ibuprofen for rapid relief in acute joint pain.

BACKGROUND: To study the effect of Lanconone® (1000 mg) on acute pain on exertion as compared to the standard of care, Ibuprofen (400 mg). METHOD: The study recruited 72 subjects diagnosed with mild to moderate knee joint pain on exertion. Subjects with Pain Visual Analogue Scale of more than 40 mm were included. Uphill walking was provided as the stressor using Naughton's protocol on a treadmill. The subjects walked for 10 minutes continuously followed by a rest period and baseline pain score for index knee joint was recorded. Subjects were administered a single dose of Lanconone® (1000 mg)/Ibuprofen (400 mg). Thereafter the same stressor was provided at 0.5, 1, 2, 3, 4, and 6 hours, subsequently, pain scores were recorded on a visual analogue scale. Double stopwatch method was used to evaluate the onset of pain relief and time taken to meaningful pain relief. RESULT: Both Lanconone® and Ibuprofen showed the first perceived pain relief at 65.31 ± 35.57 mins as compared to 60.82 ± 32.56 mins respectively. The mean time taken to experience meaningful pain relief in Lanconone® group was 196.59 ± 70.85 mins compared to 167.13 ± 71.41 mins amongst Ibuprofen group. The meaningful pain relief continued for 6 hours. CONCLUSION: The current study successfully demonstrated rapid pain-relieving potential of Lanconone® which was comparable to Ibuprofen. No adverse event related to the interventions was reported in the study. TRIAL REGISTRATION: Clinical trials.gov NCT02417506 . 21 January 2015.

Recent advances in massage therapy--a review.

Massage therapy is one of the most widely accepted alternative form of medicine helping patients suffering from varied pathological states including arthritis, anxiety, sleep problems, pain management and injury repair. Besides this, it is one of the safest forms of alternative medicine and has become favorite among various health care professionals. However, there is still a lot of debate is going in medical world pertaining to its certain use in modern medicine. So, the present review shall enlighten all the latest aspects of massage therapy in current medicine.

Analysis of provider specialties in the treatment of patients with clinically diagnosed back and joint problems.

RATIONALE, AIMS AND OBJECTIVES: Although several studies have compared patient outcomes by provider specialty in the treatment of back and joint pain, little is known about the cost-effectiveness of improving patient outcomes across specialties. This study uses a large-scale, nationally representative database to evaluate the cost-effectiveness of being treated by specific provider specialists for back and joint pain in the United States. METHOD: The 2002-2012 Medical Expenditure Panel Surveys were used to examine patients diagnosed with back and/or joint problems seeking treatment from doctors (internal medicine, family/general, osteopathic medicine, orthopaedics, rheumatology, neurology) or other providers (chiropractor, physical therapist, acupuncturist, massage therapist). A total of 16,546 respondents aged 18 to 85 and clinically diagnosed with back/joint pain were examined. Self-reported measures of physical and mental health and general quality of life (measured by the EuroQol-5D) were compared with average total costs of treatment across medical providers. RESULTS: Total annual treatment costs per person ranged from $397 for family/general doctors to $1205 for rheumatologists. Cost-effectiveness analysis suggests that osteopathic, family/general, internal medicine doctors and chiropractors and massage therapists were more cost-effective than other specialties in improving physical function to back pain patients. For mental health measures, family/general and orthopaedic doctors and physical therapists were more cost-effective compared with other specialties. Similar to results on physical function, family/general, osteopathic and internal medicine doctors dominated other specialties. However, only massage therapy was cost-effective among non-doctor providers in improving quality of life measures. CONCLUSIONS: Patients seeking care for back and joint-related health problems face a wide range of treatments, costs and outcomes depending on which specialist provider they see. This study provides important insight on the relationship between health care costs and patients' perceived physical and mental health status from receiving treatment for diagnosed back/joint problems.

Electro-acupuncture for treatment of knee pain from osteoarthritis and the possible endocrinology changes: a study protocol for a randomized controlled trial.

BACKGROUND: Osteoarthritis of the knee is a major cause of disability among adults. Electro-acupuncture is considered a potentially useful treatment for osteoarthritis. The purpose of this study is to assess the efficacy of electro-acupuncture on pain control, pain perception, plasma cortisol and beta-endorphin levels, patient-perceived quality of life, and pain medication use in patients with chronic knee pain. METHODS/DESIGN: This study is a placebo-controlled, randomized, double-blind, parallel design trial. One hundred sixty out-patients who are more than 50 years old and who have osteoarthritis of the knee will be recruited from the island of Mallorca, Spain. Each participant will be randomly placed into one of two groups: (sham) electro-acupuncture non-insertion technique and real electro-acupuncture. Acupuncture treatments will be the Traditional Chinese Medicine type. The patients will be evaluated after a period of 1 month (with two weekly sessions), 3 months (with one monthly session), 6 months (with one session every 45 days), and 1 year later with follow-up sessions at the end of the study (with one session every 2 months). The primary outcomes will be based on the observed changes from the baseline of the visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for pain measured at 12 weeks after the end of treatment. Also to be included in the study are the possible changes in the secondary efficacy variables from baseline as assessed by the Short Form 36 version 2 health survey (patient-perceived quality of life), patient plasma cortisol and beta-endorphin levels at the different treatment stages, the Goldberg Anxiety and Depression Scale, pain medication use, functional capacity and stiffness (WOMAC subscales), and a VAS. These variables will be assessed at 1 month, 3 months, 6 months, and 1 year after study commencement. DISCUSSION: The findings from this study will help to determine whether electro-acupuncture is effective for chronic knee pain management in older people and whether electro-acupuncture can deliver results for the improvement of pain relief, stiffness, and disability. The study will therefore be a major step toward understanding the roles of the hypothalamic-pituitary-adrenal axis and the endogenous opioid system in the effectiveness of electro-acupuncture for chronic pain. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02299713 (11 Nov. 2014).

Can therapy dogs improve pain and satisfaction after total joint arthroplasty? A randomized controlled trial.

BACKGROUND: The use of animals to augment traditional medical therapies was reported as early as the 9th century but to our knowledge has not been studied in an orthopaedic patient population. The purpose of this study was to evaluate the role of animal-assisted therapy using therapy dogs in the postoperative recovery of patients after THA and TKA. QUESTIONS/PURPOSES: We asked: (1) Do therapy dogs have an effect on patients' perception of pain after total joint arthroplasty as measured by the VAS? (3) Do therapy dogs have an effect on patients' satisfaction with their hospital stay after total joint arthroplasty as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)? METHODS: A randomized controlled trial of 72 patients undergoing primary unilateral THA or TKA was conducted. Patients were randomized to a 15-minute visitation with a therapy dog before physical therapy or standard postoperative physical therapy regimens. Both groups had similar demographic characteristics. Reduction in pain was assessed using the VAS after each physical therapy session, beginning on postoperative Day 1 and continuing for three consecutive sessions. To ascertain patient satisfaction, the proportion of patients selecting top-category ratings in each subsection of the HCAHPS was compared. RESULTS: Patients in the treatment group had lower VAS scores after each physical therapy session with a final VAS score difference of 2.4 units (animal-assisted therapy VAS, 1.7; SD, 0.97 [95% CI, 1.4-2.0] versus control VAS, 4.1; SD, 0.97 [95% CI, 3.8-4.4], p<0.001) after the third physical therapy session. Patients in the treatment group had a higher proportion of top-box HCAHPS scores in the following fields: nursing communication (33 of 36, 92% [95% CI, 78%-98%] versus 69%, 25 of 36 [95% CI, 52%-84%], p=0.035; risk ratio, 1.3 [95% CI of risk ratio, 1.0-1.7]; risk difference, 23% [95% CI of risk difference, 5%-40%]), pain management (34 of 36, 94% [95% CI, 81%-99%], versus 26 of 36, 72% [95% CI, 55%-86%], p=0.024; risk ratio, 1.3 [95% CI of risk ratio, 1.1-1.6]; risk difference, 18% [95% CI of risk difference, 5%-39%]). The overall hospital rating also was greater in the treatment group (0-10 scale) (9.6; SD, 0.7 [95% CI, 9.3-9.8] versus 8.6, SD, 0.9 [95% CI, 8.3-8.9], p<0.001). CONCLUSIONS: The use of therapy dogs has a positive effect on patients' pain level and satisfaction with hospital stay after total joint replacement. Surgeons are encouraged to inquire about the status of volunteer-based animal-assisted therapy programs in their hospital as this may provide a means to improve the immediate postoperative recovery for a select group of patients having total joint arthroplasty. LEVEL OF EVIDENCE: Level II, randomized controlled study. See Instructions for Authors for a complete description of levels of evidence.

Technical Note: Treatment of Sacroiliac Joint Pain with Peripheral Nerve Stimulation.

INTRODUCTION: Sacroiliac joint (SIJ) pain affects older adults with a prevalence of up to 20% among patients with chronic low back pain. While pain medication, joint blocks and denervation procedures achieve pain relief in most patients, some cases fail to improve. Our goal was to determine the effectiveness of SIJ peripheral nerve stimulation in patients with severe conservative therapy-refractory SIJ pain. MATERIALS AND METHODS: Here we present 12 patients with severe conservative therapy-refractory pain receiving an SIJ peripheral nerve stimulation. Patient satisfaction, pain, and quality of life were evaluated by means of the International Patient Satisfaction Index (IPSI), visual analog scale (VAS), and Oswestry Disability Index 2.0 (ODI) using standard questionnaires. For stimulation we placed an eight-pole peripheral nerve electrode parallel to the SIJ. RESULTS: Two weeks postoperatively, our patients reported an average ODI reduction from 57% to 32% and VAS from 9 to 2.1. IPSI was 1.1. After six months, the therapy was rated as effective in seven out of eight patients reporting at that period. The average ODI was low at 34% (p = 0.0006), while the VAS index rose to 3.8 (p < 0.0001) and IPSI to 1.9. Twelve months after stimulation, six out of seven patients considered their treatment a success with an average ODI of 21% (p < 0.0005), VAS 1.7 (p < 0.0001), and IPSI 1.3. CONCLUSIONS: We conclude that SIJ stimulation is a promising therapeutic strategy in the treatment of intractable SIJ pain. Further studies are required to determine the precise target group and long-term effect of this novel treatment method.

Electroacupuncture for fatigue, sleep, and psychological distress in breast cancer patients with aromatase inhibitor-related arthralgia: a randomized trial.

BACKGROUND: Although fatigue, sleep disturbance, depression, and anxiety are associated with pain in breast cancer patients, it is unknown whether acupuncture can decrease these comorbid symptoms in cancer patients with pain. The objective of this study was to evaluate the effect of electroacupuncture (EA) on fatigue, sleep, and psychological distress in breast cancer survivors who experience joint pain related to aromatase inhibitors (AIs). METHODS: The authors performed a randomized controlled trial of an 8-week course of EA compared with a waitlist control (WLC) group and a sham acupuncture (SA) group in postmenopausal women with breast cancer who self-reported joint pain attributable to AIs. Fatigue, sleep disturbance, anxiety, and depression were measured using the Brief Fatigue Inventory (BFI), the Pittsburgh Sleep Quality Index (PSQI), and the Hospital Anxiety and Depression Scale (HADS). The effects of EA and SA versus WLC on these outcomes were evaluated using mixed-effects models. RESULTS: Of the 67 randomly assigned patients, baseline pain interference was associated with fatigue (Pearson correlation coefficient [r]=0.75; P < .001), sleep disturbance (r=0.38; P=.0026), and depression (r=0.58; P < .001). Compared with the WLC condition, EA produced significant improvements in fatigue (P=.0095), anxiety (P=.044), and depression (P=.015) and a nonsignificant improvement in sleep disturbance (P=.058) during the 12-week intervention and follow-up period. In contrast, SA did not produce significant reductions in fatigue or anxiety symptoms but did produce a significant improvement in depression compared with the WLC condition (P=.0088). CONCLUSIONS: Compared with usual care, EA produced significant improvements in fatigue, anxiety, and depression; whereas SA improved only depression in women experiencing AI-related arthralgia.

Internet-mediated physiotherapy and pain coping skills training for people with persistent knee pain (IMPACT - knee pain): a randomised controlled trial protocol.

BACKGROUND: Persistent knee pain in people over 50 years of age is often attributable to knee osteoarthritis (OA), a common joint condition that causes physical and psychological dysfunction. Exercise and pain coping skills training (PCST) can help reduce the impact of persistent knee pain, however, access to health professionals who deliver these services can be challenging. With increasing access to the Internet, remotely delivered Internet-based treatment approaches may provide alternatives for healthcare delivery. This pragmatic randomised controlled trial will investigate whether an Internet-delivered intervention that combines PCST and physiotherapist-guided exercise (PCST + Ex) is more effective than online educational material (educational control) in people with persistent knee pain. METHODS/DESIGN: We will recruit 148 people over 50 years of age with self-reported persistent knee pain consistent with knee OA from the Australian community. Following completion of baseline questionnaires, participants will be randomly allocated to access a 3-month intervention of either (i) online educational material, or (ii) the same online material plus an 8-module (once per week) Internet-based PCST program and seven Internet-delivered physiotherapy sessions with a home exercise programs to be performed 3 times per week. Outcomes will be measured at baseline, 3 months and 9 months with the primary time point at 3 months. Primary outcomes are average knee pain on walking (11-point numeric rating scale) and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index subscale). Secondary outcomes include additional measures of knee pain, health-related quality-of-life, perceived global change in symptoms, and potential moderators and mediators of outcomes including self-efficacy for pain management and function, pain coping attempts and pain catastrophising. Other measures of adherence, adverse events, harms, use of health services/co-interventions, and process measures including appropriateness and satisfaction of the intervention, will be collected at 3, 6 and 9 months. DISCUSSION: The findings will help determine the effectiveness and acceptability of Internet access to a combination of interventions that are known to be beneficial to people with persistent knee pain. This study has the potential to guide clinical practice towards innovative modes of healthcare provision. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry reference: ACTRN12614000243617.